&Cancer Fertility

Fertility Options to Consider Before Treatment Begins & Parenthood Options After Cancer

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If you or someone you care about

is faced with a cancer diagnosis,

preserving fertility may be one of

the last things on your mind. But

if you’re a woman of childbearing

age or a man who is concerned

about his future ability to become

a father, it is important to

understand that the treatments

that help fight cancer may also

affect your ability to have children.

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Fortunately, there are more options to preserve your fertility than everbefore. If you want to be a parent after treatment, you may still be ableto fulfill your dream. Whether you are a newly diagnosed patient or along-term survivor, several parenting options may be available for youto consider.

This booklet offers some up-to-date information about infertilityrisks, fertility preservation options and parenting options after cancer.It is hoped that this information will help you and your doctor makedecisions that are right for you.

Fertility RisksDifferent cancer treatments affect the body in different ways.Chemotherapy, radiation and surgery can all affect your reproductivesystem. In general, the higher the dose and the longer the treatment,the higher the chance for reproductive problems. Your age, the type of drugs, the area of radiation and other factors can influence yourrisk. Ask your doctor how your treatments might affect you.

CancerCancer itself can cause infertility. For example, some men with testicularcancer and Hodgkin’s disease have low sperm counts before treatmenteven starts.

ChemotherapyChemotherapy can damage both sperm and eggs. Chemotherapydrugs in the alkylating class are the most detrimental but others, likeplatinum-based drugs, are also damaging. Individual treatment factorssuch as patient age, drug type(s), and total drug dosage may affect thechance of becoming infertile.

RadiationRadiation therapy can also impair the reproductive system. If the radi-ation field includes the brain, it may affect fertility by damaging areasthat control hormone production. Radiation therapy aimed close to, orat the pelvic area of the body, can cause infertility by directly affectingthe testicles or ovaries.

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SurgerySurgery that removes part or all of your reproductive system canimpair or even eradicate your fertility potential. If the cancer involvesyour testicles, ovaries, uterus, cervix or the nerves and lymph nodes inthe abdomen and pelvis, talk to your doctor about the effects of thesurgery on your fertility and/or your ability to establish a pregnancy orif you are a woman, to maintain a pregnancy.

Other treatments that may be deemed necessary for you may alsodamage fertility. Ask your doctor to help determine the fertility risksassociated with your individual treatment regimen.

DefinitionsInfertilityFor men, infertility may occur when you no longer make sperm, thesperm are few in number or they have been damaged by cancer treat-ment. Infertility is not the same as impotence, which is the inability tohave an erection sufficient for intercourse.

For women, infertility occurs when you no longer produce matureeggs or have some other condition that prevents you from becomingpregnant or maintaining the pregnancy. Women are born with a cer-tain amount of eggs in their ovaries. Some or all of these eggs can bedamaged and destroyed from cancer treatments. Because you do notgrow new eggs, this loss of eggs can cause infertility and prematureovarian failure.

Premature Ovarian Failure (Women Only)Premature ovarian failure (or early menopause) is the loss of fertilitybefore age 40. Some women go into menopause immediately aftertreatment. This also means that they are infertile. Others will be fortu-nate to regain their fertility after treatment. Still others will have menstrual periods again but the egg supply may have been damaged sothey enter menopause early.

If you go into menopause early, you may need to take calcium sup-plements and hormone replacements, like the birth control pill. Talk toyour doctor to learn how to treat premature ovarian failure.

Men – Fertility Preservation Options Before TreatmentSperm FreezingSperm banking is a simple, proven way to try topreserve your fertility. Sperm may be frozen and“banked” for future use. Sperm samples can becollected as frequently as daily or every otherday to be cryopreserved (frozen). Even if your

sperm count is low or you only have time to make one deposit, spermbanking may still be worthwhile. There are new technologies thatrequire few sperm to achieve pregnancy. Once sperm is frozen, there isno set time limit as to how long it can remain frozen until it is used.

Testicular tissue freezing is an option for some men who cannotbank sperm because of the inability to ejaculate. When sperm are presentin the testicle but not in the semen, it is a relatively straight forwardoutpatient surgical procedure to remove sperm-bearing tissue from thetesticles and freeze it for future use.

Radiation shielding should be requested when appropriate. Thedoctor places special lead-lined shields over one or both testicles. If youare having radiation to the lower abdomen or pelvic area, this may helpreduce the risk of damage to your fertility.

After Treatment Diagnosing InfertilityA semen analysis is a simple test that can be performed by a doctorafter you finish treatment to see if you are producing sperm. The resultsof the test will help you decide the best options for becoming a parent.Sometimes sperm production will restart after cancer treatment. Thismay take a couple of years of it can occur sooner, but you couldbecome fertile again. Since you do not know when or if it will return,you should consider using some form of birth control if you are notready to become a father.

Parenthood Options After CancerNatural conception can occur if your semen analysis is in the normalor near normal range. Many cancer survivors have children after treat-ment. Before you decide to try to have children, you should talk to yourdoctor about how long you should wait after radiation or chemotherapybecause these treatments may affect the genetic material in the spermproducing cells and repair of the damage that is caused may take a yearor so depending on the type of treatment.

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Assisted reproduction may be an option if your sperm count orquality is low or if there is no sperm in your semen. Male infertilityspecialists should be consulted to determine if they can help you. Ifyou banked sperm, a doctor can use that sperm in a process called invitro fertilization (IVF) to impregnate your wife or partner. If you didn’tbank sperm, a doctor may be able to find and extract sufficient numbersof sperm in your testicular tissue. A single sperm can now be injectedinto an egg to establish a pregnancy.

Donor sperm from another man can be used if no sperm is foundin either your semen or testicular tissue. Sperm donation programsallow you to select an anonymous donor whose traits and characteris-tics closely match your own.

Adoption is an excellent choice for many couples wanting tobecome parents. Adoption agencies may look at your medical historyor require a letter from your doctor about your health. It is a good ideato select an agency that is open to working with cancer survivors.

WomenFertility Preservation Options Before TreatmentEmbryo FreezingEmbryo freezing is a proven, successful way to try to preserveyour fertility. It requires sperm, so it is a good option to considerif you are married, have a committed partner or are willing touse donor sperm. The process requires hormonal stimulation toretrieve your eggs and takes two to six weeks.

Egg FreezingEgg freezing is an experimental option for women who do not want tofertilize their eggs to freeze embryos. Pregnancy rates are lower thanembryo freezing (unfertilized eggs are more delicate and can easily bedamaged during cryopreservation), but the techniques are improving.The process requires hormonal stimulation to retrieve your eggs. It,like embryo freezing, also takes two to six weeks.

Ovarian Tissue FreezingOvarian tissue freezing may be a good option if you do not have a lotof time before treatment or if you cannot have the hormonal stimula-tion needed for egg retrieval and either embryo or egg freezing. Thisapproach, which also is considered experimental, involves the surgicalremoval and freezing of ovarian tissue.

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After chemotherapy and/or radiation therapy is completed, theovarian tissue can be thawed and transplanted to the pelvis or arm. Ifthe ovarian tissue is transplanted to the pelvis, the hope is that the tissuewill begin to function normally and that an egg will be picked up by thefallopian tube, thus allowing “normal conception.” If the ovarian tissueis transplanted to the arm and begins to function, eggs can be removedand used for in vitro fertilization.

In the future, ovarian tissue freezing might also be able to restorehormonal function. This would be a benefit if you go into earlymenopause.

Ovarian Shielding & Ovarian TranspositionThese are methods of minimizing radiation to your ovaries. By decreas-ing the amount of radiation, you can decrease the amount of damageto your ovaries and your eggs. If you are receiving radiation treatmentto your abdominal area, these options should be discussed with yourdoctor. These methods do not protect the ovaries from chemotherapy.

Fertility Sparing SurgeryThere are now many surgical options for gynecologic cancers that may help preserve your fertility. If you have a gynecological cancer,ask your oncologist what fertility-sparing surgical options may be available for you.

Suppression of Ovarian Activity During Chemotherapy While controversial, there is some data to indicate that suppressing theactivity of the ovary with medications called gonadotropin releasinghormone agonists (GnRHa) may lessen the negative impact ofchemotherapy on future ovarian function. Studies are now being doneto try to determine if this medication is of benefit. You should discussthis option with your oncologist and reproductive endocrinologist.

Assessing Fertility After TreatmentIf you are having periods without the aid of hormonal supplements like birth control pills, you may still be fertile. A reproductive endocri-nologist can use simple hormone tests and ultrasound to measure theapproximate number of eggs you have in your ovaries.

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Parenthood Options After CancerNatural ConceptionNatural conception may be possible if you remain fertile after treat-ment. Many women are able to get pregnant naturally after cancertreatments.

Assisted ReproductionAssisted reproduction methods like embryo freezing, egg freezing andovarian tissue freezing, are usually thought of as pre-treatment options.They can also be done after cancer treatment. If you are fertile, butworried that you might go into early menopause before you are readyto start a family, you may want to preserve your fertility after treatment.

Donor Eggs & EmbryosDonor eggs and embryos can be used if you do not have any healthyeggs after treatment. Egg donation allows you to select an anonymousdonor whose traits and characteristics closely match your own. Thedonor eggs can be fertilized with your partner’s sperm to createembryos. Embryo donation allows you to use embryos from coupleswho have extra embryos and have completed their own families. Ineither case, the embryos are transferred to your uterus. This means that even if you are in early menopause, you may be able to carry apregnancy and give birth.

Gestational SurrogacyGestational surrogacy is the term used when another woman carries ababy for you. This may be an option if your doctor feels that pregnancyis unsafe or if you are unable to carry a child. If you are not in earlymenopause, your eggs can be fertilized with your partner’s sperm andthe resulting embryo implanted into a surrogate. The surrogate wouldthen carry your biological child. If you cannot use your own eggs,donor eggs or embryos can be used. Surrogacy laws vary from state to state, so it is important to understand the surrogacy laws where you live.

AdoptionAdoption is an excellent choice for anyone wanting to become a parent.Adoption agencies may look at your medical history or require a letterfrom your doctor about your health. It is a good idea to select anagency that is open to working with cancer survivors.

Safety of Pregnancy & Children After CancerCurrent available studies suggest the following:• Pregnancy after cancer does not reduce chances of the patient’s

survival (i.e. trigger cancer recurrence), even after breast cancer.• Radiation to the uterus can increase the risk of miscarriage or pre-

mature births.• The stress of pregnancy can sometimes worsen undetected damage

from cancer treatment to a woman’s heart or lungs.• Sperm cells exposed to chemotherapy or radiation may suffer

genetic damage. This damage appears to be repaired one to twoyears after treatment.

• Growing eggs exposed to chemotherapy or radiation may suffergenetic damage. This damage appears to be repaired within sixmonths.

• Rates of birth defects in the general population are 2% to 3%.Rates of birth defects in children born after one parent’s cancertreatment appear similar; no higher than 6% and probably less.

• No unusual cancer risk has been identified in the offspring of can-cer survivors (except in families identified with true genetic cancersyndromes, for example, inherited retinoblastoma).syndromes, forexample, inherited retinoblastoma).

Research thus far is reassuring, but the number of pregnancies andbirths studied after cancer treatment is still small; larger studies couldreveal additional health risks. Please consult your medical team whenconsidering conception and pregnancy after cancer treatment

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ConclusionMany options exist for you to become a parent. Thinking about fertilitynow can help assure you have choices when you are ready to become aparent. Talk to your medical team about your treatment and its effectson your fertility. Your oncologist can refer you to a reproductive spe-cialist. Social workers, religious advisors, psychologists and other sur-vivors can also help you understand your fertility choices.

The following are some sample questions you may want to ask:• Will my treatment have any short or long term side effects on my

reproductive system?• Is infertility a possible side effect of my treatment?• Are there alternative ways to treat my cancer that will result in less

damage to my reproductive system?• What are my fertility preservation options before, during and after

treatment?• Would using any of these options possibly make my cancer treat-

ment less effective?• After treatment, how will I know if I am infertile or fertile?• After treatment, will I enter into menopause prematurely?

(women only)• If I become menopausal after this treatment, is the change more

likely to be temporary or permanent? (women only)• If I become infertile after treatment, what are my options for

becoming a parent?• How long after treatment should I wait before trying to conceive?

Fertile Hope: Fertility Resource for Cancer PatientsFounded in 2001, Fertile Hope is a national nonprofit organization dedicated to provid-ing reproductive information, support and hope to cancer patients whose medical treat-ments present the risk of infertility. For more information, please call (888) 994-HOPEor visit www.fertilehope.org.

© The Cleveland Clinic and Fertile Hope 2/2005

1 “Male Health Issues after Treatment for Childhood Cancer,” Children’s Oncology Group, 2003.

2 Maria Hewitt, et al., eds. Childhood Cancer Survivorship: Improving Care and Quality of Life,The National Academy of Sciences, 2003.

3 Loredana Gandini, et al., “Testicular cancer and Hodgkin’s disease: evaluation of semen quality,”Human Reproduction, Vol. 18 No. 4, April 2003, pp. 796-801.

4 Ibid.

5 “Female Health Issues after Treatment for Childhood Cancer,” Children’s Oncology Group, 2003.

6 S. Postovsky, et al., “Sperm cryopreservation in adolescents with newly diagnosed cancer,”Medical and Pediatric Oncology, Vol. 40, 2003, pp. 355-359.

7 Angela B. Thomson, et al., “Late reproductive sequalae following treatment of childhood cancer and options for fertility preservation,” Best Practice & Research Clinical Endocrinology and Metabolism, Vol. 16, No. 2, 2002, pp. 311-334.

8 “Recommendation for the use of specific area gonad shielding on the patient,” FDA Center for Devices and Radiological Health, Sec. 1000.50,http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?CFRPart=1000&showFR=1.

9 “What tests are used to diagnose male infertility?” UC Davis Health System,http://www.ucdmc.ucdavis.edu/ucdhs/health/a-z/67Infertilitymen/doc67diagnosis.html.

10 Samantha M. Pfeifer and Christos Coutifaris, “Reproductive Technologies 1998: Options Available for the Cancer Patient,” Medical and Pediatric Oncology, Vol. 33, pp. 34-40.

11 Angela B. Thomson, et al., “Late reproductive sequalae following treatment of childhood cancer and options for fertility preservation,” Best Practice & Research Clinical Endocrinology and Metabolism,Vol. 16, No. 2, 2002, pp. 311-334.

12 Mark F. H. Brougham, et al., “Male fertility following childhood cancer: current concepts and future therapies,” Asian Journal of Andrology, Vol. 5, Dec. 2003, pp. 325-337.

13 “Fertility After Cancer…Options for Starting a Family,” Virtual Hospital, The University of Iowa Hospitals and Clinics, http://www.vh.org/adult/patient/cancercenter/fertility/fertilitytext.html.

14 Ibid.

15 Fady I. Sharara, Healthology Press,http://imagecaredrugs.healthology.com/focus_article.asp?f=fertility&b=healthology&c=ovarianreserve_article.

16 “Fertility After Cancer…Options for Starting a Family,” Virtual Hospital, The University of Iowa Hospitals and Clinics, http://www.vh.org/adult/patient/cancercenter/fertility/fertilitytext.html.

17 Find out an average rate

THE CLEVELAND CLINICFOUNDATION

9500 Euclid Avenue, Cleveland, OH 44195

The Cleveland Clinic is an independent,not-for-profit, multispecialty academic medical

center. It is dedicated to providing qualityspecialized care and includes an outpatient clinic,

a hospital with more than 1,000 staffed beds,an education division and a research institute.

© The Cleveland Clinic Foundation 8/2005

Next StepsFor more information, or to schedule a consultation:

Women:The Cleveland Clinic Fertility Center at Beachwood (216) 839-3150http://www.clevelandclinic.org/obgyn/

The Cleveland Clinic Department of Obstetrics & Gynecology at the Main Campus (216) 444 1758http://www.clevelandclinic.org/obgyn/

Men:If you want to sperm bank, a doctor needs to give you a prescription todo this. If you have a prescription, you may start the process by callingthe Cleveland Clinic Andrology Laboratory and Sperm Bank (216-444-8182 or 1800 223-2273, ext. 48182) to set up a convenientappointment for you to go to the bank. The laboratory is located onthe main campus on first floor of the Crile Building at East 100 andCarnegie Ave. It will be open weekdays and weekends if needed forbanking.

If you have questions regarding your fertility preservation, you maycall the Director of the Laboratory (216-444-9485) or the physicianwho is head of the section of male infertility at 216-444-6340. Theywill be happy to work with you and your doctor to assist you in pre-serving your fertility potential.